Is PRP an effective, new Tennis Elbow treatment - Or an overpriced fad, driven by star-athlete publicity and marginal science?
Platelet-Rich Plasma (PRP) therapy certainly looks like it could be a promising, new treatment approach to stubborn, chronic tendon problems, like Golfer's Elbow and Tennis Elbow.
And, along with its lessor relative, Autologous Blood Injection (ABI) it has excellent upsides: It's a quick procedure; minimally invasive; uses your own cells – not some toxic drug – and is unlikely to have any major negative effects.
Compared to nearly ever other medical intervention for Tennis and Golfer's Elbow (and other Tendinopathies) I would really like to be positive about this one. I certainly like the theory behind it!
(I'm negative about almost all the conventional Tennis and Golfer's Elbow treatment approaches, as you can see on this blog, for very good reasons, so it's nice to be able to say something positive.)
But, the question is, will PRP prove to be an effective, reliable remedy backed by scientific evidence or will it turn out to be just another expensive, overrated fad?
Some say the writing is already on the wall – Others say it's still too early to tell. So let's take a look at what PRP is, how it's supposed to work and, finally, I'll weigh in with my two cents.
Table Of Contents Of This Article:
(Links jump down the page to various sections of this article.)
- What is Platelet-Rich Plasma Therapy?
- What's the difference between PRP and Autologous Blood (ABI) Injection?
- How does it work? What's the theory behind PRP and ABI?
- Is PRP an effective treatment for Tennis Elbow and Golfer's Elbow?
- What's my opinion as a practitioner who specializes in treating Tennis Elbow?
Podcast Version On The PRP Question
In this podcast episode I discuss the pros and cons of Platelet-Rich Plasma Therapy. (It's actually the same as the video above.) Scroll down for the podcast subscribe link.
Here's the downloadable version of this podcast you can keep by clicking the "download" link under the player below - And please subscribe on your favorite platform:
PRP therapy is an in-office “non-surgical” procedure (they say “non-surgical” - but I would classify it as a minor surgery) that begins by having a small amount of your own blood drawn.
Your blood is then spun in a centrifuge to concentrate the platelets in it (which also separates them from your red and white blood cells.)
In the photo below Dr. Allan K. Mishra, Orthopedist at Stanford University's Menlo Clinic in Menlo Park, California, holds up and displays a tube containing centrifuged blood.
Next, your platelets along with some of your plasma are injecting back into your body in the area that has the injury that isn't healing well.
Platelets are the cells in the blood that are mostly responsible for blood clotting, and platelets also secrete growth factors (including human growth hormone) that are involved in tissue healing.
In the case of Tennis Elbow or Golfer's Elbow, your Platelet-Rich Plasma is injected into either your Wrist Extensor Tendon Origin at your Lateral Epicondyle (the Tennis Elbow “spot”) or your Flexor Origin on the medial side (the Golfer's Elbow “spot.”)
Podcast: Doctor's Interview Explaining Theory And History Of PRP
Here's a short podcast from NPR with host, Robert Siegel, interviewing Dennis Cardone, Assoc. Prof. of Orthopedic Surgery at NYU's Langone Medical Center, who explains the basic theory of how PRP works, the story of how it became so popular and questions its effectiveness:
"There are some studies out, but let's just say that the evidence is not as good as we would like it to be. So, we'd like to see more of the double-blind randomized control, better-evidenced based studies."
What your Doctor may not tell you in advance is that they jab that needle into your tendon in not just one spot, but in several different places (up do a dozen?)
I've heard from a few of my patients, personally, and several people commenting on my Facebook page and in my members forum, that the process can be very, very painful!
(For some reason some Doctors apparently don't use any local anesthetic when they give you these injections – which can be excruciating – but even if they do anesthetize you during the procedure, I hear it can still hurt like hell for days afterward.)
The main difference between Autologous Blood Injection (ABI) and PRP is that they don't take the step of centrifuging your blood to concentrate the platelets first before injecting it back into your tendon(s.)(Autologous simply means cells or tissues obtained from the same person.)
The platelets are still there, just not in as high a concentration as with PRP.
The advantage is that Autologous Blood Injection treatments are usually a lot less expensive that PRP treatments.
PRP treatments run from around $500. to as much as $2000. per visit, and sometimes multiple visits are required.
And no known insurer covers PRP or ABI injection treatments, as there isn't enough evidence, via medical studies, (which we'll get to shortly.)
I can't find a good source for the price range of ABI treatments. My guess would be that it varies even more that PRP from clinic to clinic and city to city but my impression is that the savings are substantial.
It's much more low tech considering that it's basically just “blood out over here – then back in over there” hopefully guided by ultrasound, though.
The objective of PRP of ABI is to use your body's own cells, proteins and healing factors to stimulate and start (or re-start) a healing process in your tendon(s.)
To kick-start healing that has either stalled and remained incomplete or never started in the first place, and that begins with inflammation.
Yes! You read that correctly. To instigate a healing response, which always begins with inflammation.
Probably the most fascinating thing to me about PRP is the radical reversal from the standard anti-inflammatory medical approach to Tennis Elbow.
Instead of fighting inflammation – They are finally encouraging it! (Although they often seem to be a little vague about that key point.)
For decades, Doctors, medical websites, trainers and Physical Therapists have emphatically instructed Tennis Elbow, Golfer's Elbow and other tendon injury sufferers to treat or “manage” their inflammation.
(As if your body possessed no self-regulation and didn't know what the proper inflammatory response to an injury should be and, hence, like a recalcitrant, new puppy, necessitating constant micromanagement by way of pills, ice and shots.)
Unfortunately, most STILL DO advise you to take this faulty “treat and defeat inflammation” approach for weeks or months on end before trying something else…
But how much damage is done during that time by fighting and suppressing one's own natural healing process!?
Now it's FINALLY being recognized by top authorities in Sports Medicine, Athletic Training and other disciplines that inflammation is not the villain it has been made out to be.
Here's one recent study where the doctors authoring the study acknowledge that the typical, common wisdom treatments, like anti-inflammatories, (NSAIDs) Cortisone shots – and let's not forget ICE! – Don't work, because they can't overcome the tendon's poor blood supply and innate tendency to “resist” healing...
AND that the goal of these types of treatment, including Prolotherapy and PRP is to induce – NOT suppress – inflammation!
“Epicondylitis was initially believed to be an inflammatory process but in 1979, it was described as the disorganization of normal collagen architecture...”
“The effectiveness of oral nonsteroidal anti-inflammatory agents, topical and injectable medications including corticosteroids and botulinum toxins, splinting, physical therapy, and iontophoresis has been evaluated in many studies...”
“However, these traditional therapies do not alter the tendon's inherent poor healing properties secondary to poor vascularization.”
“Given the inherent nature of the tendon, new treatment options including platelets rich plasma (PRP), autologous blood, and prolotherapy are aimed at inducing inflammation rather than suppressing it.”
Pain Res Treat. 2014; 2014: 191525 - Seyed Ahmad Raeissadat, et al.
As I've been saying for over a decade, inflammation is a necessary and normal part of the healing process of injured tissue so, stop fighting it!
See my post and video Tossing The Tendonitis Myth about why Tennis Elbow is NOT Inflammatory
We have to correct the myth and faulty model of Tennis Elbow that falsely accuses inflammation of being the cause of the problem, (which becomes absurdly illogical, once you learn that inflammation is a normal part of the healing process)…
But that's only if the healing process is working – or allowed to work – and it's not suppressed by icing, anti-inflammatory medications and the absolute worst culprit: Cortisone.
Video Explaining The Theory Of How PRP Works For Tennis Elbow
What we have in most cases of truly chronic Tennis or Golfer's Elbow is a tendon or tendons that have failed to heal – The tendon(s) have NOT undergone the proper inflammatory response and subsequent repair.
And these tendons have instead gradually slipped into a degenerative breakdown state known as Tendinosis. (And sometimes there is some degree of tearing in the tendon or its attachment.)
The intention with PRP is to reverse this backward slide and re-energize the healing process through the injection of the platelets (and their healing factors) from ones own blood into the site – which kicks off a significant inflammatory response!
The traumatic process of repeatedly “stabbing” the needle into several areas of the tendon (which, by itself, would be referred to as 'Fenestration' – a technique that may have been pioneered on horses) may also help by bringing new blood into the area and triggering healing all by itself.
And, apparently, if things go as expected, it will be very painful for several days as the areas becomes inflamed. Multiple injections are often required, spaced over several weeks, months or whatever the Doctor thinks is best.
See also my article / video on Dry Needling – one form of which is basically like PRP and Prolotherapy – only without injecting anything.
It seems that many medical studies have been done and many more are recruiting test patients and are underway right now. Some studies (many, but not all specific to Tennis Elbow) do show a positive result, but others show no significant result or none at all. Here are a few of them.
PRP And ABI Therapy Medical Studies With Positive Results
“Treatment of patients with chronic elbow tendinosis with buffered platelet-rich plasma reduced pain significantly in this pilot investigation. Further evaluation of this novel treatment is warranted.” [140 patients evaluated in study]
Am J Sports Med. 2006 Nov;34(11):1774-8 - Mishra A, Pavelko T.
Later, Dr. Allan Mishra, (lead author of the above study and seen in the photo in the NY Times article linked above) conducted a more comprehensive study of 230 patients with his colleagues:
“No significant differences were found at 12 weeks in this study. At 24 weeks, however, clinically meaningful improvements were found in patients treated with leukocyte-enriched PRP compared with an active control group.”
Here's a fast and easy breakdown of the 24-week results:
Improvements in patient pain scores:
Control group: 56.1% improvement
PRP group: 71.5% improvement
Percentage reporting significant elbow tenderness at 24 weeks:
Control group: 54.0%
PRP group: 29.1%
Success rates for patients at 24 weeks:
Control group: 68.3%
PRP group: 83.9%
Am J Sports Med. 2014 Feb;42(2):463-71 - Mishra AK, et al.
It's the largest and most specific study I've come across: One group in the study got an actual PRP injection, the other got a “sham injection,” meaning a needle inserted with nothing injected (as a placebo effect control group measure)
It's a meaningful and statistically-significant result, but how excited should one be about it?
The patients who were jabbed by a needle but got no injection improved by an average of at least 50% - Which can be attributed to the placebo effect or the effect of the needle alone.
One of the things they point out, is that not all PRP preparations are the same, which might account for some of the variations in the findings of various studies.
In the next study, 40 patients with Tennis Elbow divided into 2 groups. One group got a PRP injection and the other got an autologous blood injection. The results seemed promising.
(I cited this study earlier, in reference to how the goal of the treatment is “aimed at inducing inflammation rather than suppressing it.”)
“PRP and autologous whole blood injections are both effective methods to treat chronic lateral epicondylitis.”
With PRP treatment coming out somewhat ahead in “relieving pain and improving function” at the 8-week followup.
Pain Res Treat. 2014; 2014: 191525 - Seyed Ahmad Raeissadat, et al.
Unfortunately it looks like there was no control group (which would get an injection of simply salt water or nothing at all – as the placebo test / control) so it wasn't a “double blind” study.
“The limitation of our study was the relatively small number of cases included, absence of a control group receiving no intervention, and short-term follow-up evaluations.”
PRP And ABI Therapy Medical Studies With Flat Or Negative Results
“In this prospective, randomized, controlled trial, autologous blood, corticosteroid, and saline injection provide no advantage over placebo saline injections in the treatment of lateral epicondylitis.”
J Hand Surg Am. 2011 Aug;36(8):1269-72 - Wolf JM, et al.
“There is strong evidence that PRP injections are not efficacious in the management of chronic lateral elbow tendinopathy.”
Br J Sports Med. 2014 Jun;48(12):952-6 - de Vos RJ, Windt J, Weir A.
It seems that NPR is calling it "unproven" as of June 2014, quoting a French study that I could not access and little else:
“But randomized controlled trials like the French study are all over the map. As one 2012 review put it, rather tartly: 'The observed trend towards benefit with PRP use still remains questionable.'"
“One reason for the confusion may be that there's so much variation in the ways PRP is being used, including body part being treated, how the solution is prepared, how it's injected, and even the type of injury that's being addressed.”
And the New York Times also seems to be backing off their initial enthusiasm at this point as well: 'Popular Blood Therapy May Not Work' By Gina Kolata Jan 12, 2010.
Unfortunately, it's still seems to be too early in the game to call it, but here's one more clinical trial that was expected to be completed in the Sept. of 2018 but is not showing results at the time of the updating of this article on March 7, 2019.
One of the exciting things about this trial is the inclusion of a "Sham Injection," as a placebo control group.
“At this point, it is unclear whether whole blood, concentrated platelets, or simply passing a ultrasound-guided needle through the abnormal tendon as a means to stimulate tissue healing (tendon fenestration) is the better treatment.”
“The objective of this trial is to compare platelet rich plasma, whole blood, dry needle tendon fenestration, and sham injection (with physical therapy) to identify the best and most cost-effective therapy for this debilitating condition.”
'Comparison of Platelet Rich Plasma and Alternative Therapies for the Treatment of Tennis Elbow (Lateral Epicondylitis)'
As I said in the beginning, this is a medical intervention that I can agree with – at least in theory.
Although there is a point where some sufferers will be faced with the possibility of surgery...
Here's my video on 5 key points to consider when facing surgery for Tennis Elbow
PRP might be a better alternative - or at least a last ditch effort before turning to surgery for cases that just won't respond, as long as there isn't a major tear involved.
I do like the idea of using the body's own material (blood / plasma / platelets) to attempt to “restart” a failed tendon healing process, rather than fighting that process (inflammation.)
But one of my first points of hesitation, is that there's no such thing as “minor surgery.”
Yes. This is a procedure that is “minimally invasive” and the risks of significant negative effects are very low, but whenever you pierce the skin you have risks of infection, and whenever you inject something somewhere – even if it IS your own platelets – there are risks of adverse reaction.
Personally, I don't turn to conventional medicine for even the tiniest, “minimal” interventions unless it's absolutely the last resort – I'm kind of extreme that way 😉
But what about you? What if you could accomplish the same goal as PRP without the stabbing needle, expense (and potential pain!)
Would you mind if it took some regular, daily (or at least several times a week) periods of concerted effort on your part?
The reason I ask is that, from my perspective, the most important strategy for healing a chronic, stubborn tendon problem is to reverse the stagnation.
And the best way to reverse that stagnation (lack of blood flow, lack of normal expected healing response, stuckness!) that I know of is to “work it” regularly, physically – by hand!
I believe very specific therapy techniques are needed to do this properly (which is what I teach members in the program here at Tennis Elbow Classroom, of course)
But any kind of massage / manipulation is better than nothing.
- Not total rest with the absence of all activity…
- (Or rushing too soon into rehab exercises either, which often backfires)
- Not icing it, bracing it and medicating it into submission
- But, instead, getting “in there” and NOT leaving it alone! Not allowing things to stagnate!
I do understand that the thought of manipulating by hand may seem counter-intuitive, and perhaps even a little scary at first.
Doesn't it need to be “left alone” and allowed to rest in order to heal?
No. Absolutely not! – (Except in a few extreme and rare cases where there's a known, major tendon tear.)
And you can learn how to do this yourself - Tennis Elbow is very self-treatable! - You don't necessarily have to go to see a professional therapist like myself (although that may end up being a very sensible option if you can manage it.)
And if you're already at the point after months of struggling with your Golfer’s or Tennis Elbow where you’re actively starting to consider the idea of PRP injection therapy – does it really make sense to go from one extreme to the other?
What I mean is if you've been taking the “total rest and immobilization” approach along with inflammation suppression via pills, ice and shots…
(Perhaps along with some Physical Therapy and exercises on your own – but otherwise allowing a state of stagnation to persist)…
And then when that fails, does it make sense to immediately rush to the extreme action of injecting your own blood into your tendons and trying to reverse direction all at once – suddenly encouraging inflammation?
Before you take that radical step, I just want to suggest the idea of moving gradually in that direction:
- By trying heat on the area instead of ice - Yes, heat!
- By using more stretching (the way I teach!) and gentle movement instead of bracing...
- And most importantly, by starting a program of regular hands-on manipulation of your muscles and tendons...
Even if you've already had a professional therapist of some kind work on you with little or no improvement – Because this is something you can do for yourself every single day in a very sustained manner, which is a powerful thing!
You can learn more about my programs, which teach you how to do this, below:
Learn To Treat And Heal Your Own Tennis Elbow Or Golfer's Elbow At Home With This Video Program
I'll be your personal tutor guiding you through step-by-step video lessons, where you'll get the therapy techniques, key stretches and essential exercises you need to treat and recover from your injury at home. (Without any special equipment.)
Just watch the videos, follow along and start putting an end to your elbow pain today, whether you have Golfer's or Tennis Elbow from playing your guitar - or other stringed instrument or ANY instrument, for that matter!)
Tennis Elbow sufferers: Learn more about the Tennis program here
Golfer's Elbow sufferers: Learn more about the Golfer's program here